Michael Mulford SPIR Chief of Party

1. Linking PSNP
clients with nutrition
sensitive livelihood
interventions
Michael Mulford
SPIR Chief of Party

2. Acknowledgement
This presentation was produced by World Vision under the SPIR
Program, Cooperative Agreement Number AID-FFP-A-16-00008, funded
by the U.S. Agency for International Development.

3. Strengthen PSNP4 Institutions and Resilience (SPIR)
• Implemented in Amhara (9
woredas), Oromia (6 woredas)
and SNNP (2 pilot woredas)
• Direct project participants:
500,000
• Goal: Resilience to shocks and
livelihoods enhanced, and food
security and nutrition improved,
for rural households vulnerable
to food insecurity
• USAID Food for Peace funded
Development Food Security
Activity (2016 – 2021)
• Implementing partners: CARE,
ORDA, World Vision
• Learning Partners: IFPRI,
Ambo and Hawassa University

4. SPIR Purpose areas
• Purpose 1: Increased Income, Productive Assets and Equitable
Access to Nutritious Food for Vulnerable Women, Men and
Youth
• Purpose 2: Improved nutritional status of children under two,
pregnant and lactating women, and adolescent girls
• Purpose 3: Increased Women's & Youth Empowerment &
Gender Equality
• Purpose 4: Strengthened ability of women, men and
communities to mitigate, adapt to and recover from human-
caused and natural shocks and stresses

5. PNSP4 Transfers to PW and PDS clients
• Targeting (10-15% of population within food insecure woredas)
• 6 months of transfers (cash / food) for public works payment,
and 12 months to permanent direct support beneficiaries
• Monthly individual ration size: 15kg wheat, 1.5kg pulse (YSP),
0.45kg fortified vegetable oil
• 34,394 MT of commodities distributed to 509,714 program
participants in FY18
• 274,224 PW, 55,372 PDS or TDS, 37,048 5% contingency
beneficiaries,143,070 drought affected individuals

6. Experience integrating nutrition in PSNP4
• Prioritization of public work
investments
• Household level pond
construction, or rope/pulley
pump with shallow well for
vegetable production for PLW
or women-headed HH
• Latrine construction (schools)
• Handwashing stations
• Large irrigation schemes
• Fruit trees included nursery
seedling support

7. Vegetable garden and tree nursery

8. Irrigation schemes

9. Additional activities
• VESA groups – platform for reinforcing health and nutrition
messages (harmonizing with SURE+ GoE materials in PW BCC)
• messages about increasing dietary diversity with some of new income
earned, together with cooking demonstrations
• Improved poultry breed package (inputs and training) and home-
gardening package (seeds and training) initially targeted to PLWs
• Facilitate Community Led Total Sanitation and Hygiene (CLTSH)
approach to increase number of open defecation free (ODF) villages

10. Poultry for pregnant or lactating women

11. Nutrition Sensitive Livelihoods
• Inclusion of nutrition considerations in value chain selection
• Example: poultry production
• potential for improving nutritional status of children through increased
availability of eggs and meat, provided that rearing practices do not
expose young children to fecal matter
• increasing income that is under women’s control, there is also the
expectation that investments in children’s nutrition will be improved.
• Focus on poultry production over other income generation activities
may reduce women’s time away from the home
• Use of feces in compost for home gardening

12. Household-level nutritional counseling
• Ethiopia Health Development Army (HDA) volunteer structure
• Timed and Targeted Counseling (TTC) by HDA volunteers for
both husband and wife at household level
• 11 total visits – 4 during pregnancy, 7 afterwards
• Reinforces key messages at appropriate time using storybooks
• Key nutrition messages communicated through multiple
channels: PW BCC session, VESA group discussion, household
level counseling (TTC)

13. Community Participatory Nutrition Promotion
• Engages caregivers in a two week learning-by-doing intensive
community based food demonstration and nutrition promotion
model for rehabilitating malnourished children using locally
available and affordable food in their homes
• Addresses gap between general IYCF promotion and CMAM
• Underweight children targeted (“MUAC Green”) – mild,
moderate and severe underweight (WAZ) young children
enrolled
• Model effectiveness tested using an RCT evaluation with
support from Johns Hopkins School of Public Health

14. Community Participatory Nutrition Promotion

15. Male Engagement strategy
• VESA – husband and wife both encouraged to become
members
• TTC – household level counseling not just for PLW but for
both husband and wife
• Social Analysis and Action (SAA) approach used to
enable individuals and communities to explore and
challenge social norms, beliefs and practices around
gender and nutrition that shape their lives
• Men’s groups and champions - to critically reflect on
cultural gender norms, gender relations, and explore the
positive and perceived negative effects of male
involvement in household chores, child care, etc.

16. Addressing Maternal Depression
• Postnatal depression has a significant negative impact on
breastfeeding duration. [Henderson et al, 2003]
• Infants of mothers with depressive symptoms had a 2.17 higher
odds of being stunted than did infants of mothers with few
symptoms [Black et al, 2009]
• Elimination of maternal depression could result in a reduction in
stunting of 23-29% [Surkan et al, 2014]

17. SPIR Baseline findings and IPT-G
• PHQ-9 tool used
• Women with children under three report high rates of
depressive symptoms
• 34 % feeling down, depressed or hopeless in the last 7 days
• 17 % of women had thoughts that they would be better off dead or
considered hurting themselves in the last 7 days
• Interpersonal Therapy for Groups (IPT-G) - 12-week session,
based on successful implementation in rural Uganda and
elsewhere (92% reduction in depression after treatment)

18. Impact Evaluation with IFPRI
• clustered randomized controlled trial (RCT) design
• providing rigorous estimates of the impact of the SPIR project,
• providing evidence on key project features that contribute to its
impact through comparisons of alternative implementation
strategies across treatment arms
• Including nutrition related program enhancements

19. Disclaimer
This presentation is made possible by the generous support of the
American people through the United States Agency for International
Development (USAID). The contents are the responsibility of World
Vision and do not necessarily reflect the views of USAID or the United
States Government.

20. Thank you

21. Experience integrating nutrition in PSNP4
• Targeting: Criteria includes poor households with pregnant
women and women-headed households
• Challenge: cap for household transfer calculation is 5 members, and as
such, data often missing on younger children (household member lists
also not regularly updated based on new births)
• Annual planning: Health Extension Workers (HEWs)
represented as members of Kebele Food Security Task Force
• Challenge: HEWs are overburdened and unable to play key role in
coordinating BCC sessions for PW participants and linking TDS into
social services

22. Experience integrating nutrition in PSNP4
• Transfers: 5% contingency is used to support transitory non-PSNP
HH with malnourished children in TSF / OTP treatment
• Challenge: no good system for documenting and tracking these beneficiaries
• PW BCC sessions (6 two hour sessions over 6 months)
• Dependent on HEWs to plan, coordinate and implement
• Transition of PLWs and caregivers of moderate or severe
malnourished children from PW to TDS based on HEW referrals
• Kebele officials hesitant to transfer the latter in areas with high incidence of
moderate malnutrition among PSNP households
• Lack of documentation of referrals, adherence to ANC visits, attendance of
BCC sessions, etc. even though existence of “Client Cards” to track these

23. Experience integrating nutrition in PSNP4
• Linkage to social services through soft-conditionality
• HEW refers PLW to DA for transition to TDS, but lack of follow-through
on soft-conditionality of ensuring that ANC, PNC, immunization, GMP,
etc. all followed as a part of receiving transfers
• Documentation challenges to record, track and ensure accountability